Revised 03/03/16
University of Louisville - Continuing Medical
Education & Professional Development Planning Document &
Application for ACCME CME Category 1 Credit™
The University of Louisville retains the right to withhold/adjust credit at any time, should it determine
that the ACCME Essentials, Policies, ACCME Standards for Commercial Support and/or the University of
Louisville Continuing Medical Education & Professional Development (CME&PD) policies and procedures
are violated. The accreditation of Continuing Medical Education programming is a function entrusted to
the UofL Continuing Medical Education & Professional Development by the ACCME. Adherence to all
ACCME essentials and standards is expected of the program applicants and deviation from those
essentials and standards may result in withdrawal of accreditation. If there is any question as to
compliance with the ACCME please contact the CME&PD staff immediately.
Please Note These Requirements for ACCME Accreditation by CME&PD:







In order to plan, develop and execute a successful CME course, this application needs to be completed and
emailed to cmepd@louisville.edu at least 45 days prior to your activity date, with a preferred lead time
of at least 90 days. Incomplete applications cannot be reviewed or approved by the CME&PD Advisory
Board, which has the final decision on all applications for CME credit.
Content must meet ACCME Accreditation Essentials and Standards for Commercial Support, the American
Medical Association (AMA) Physician Recognition Award requirements and all CME&PD policies and
procedures.
HIPPA compliance is the responsibility of the course director.
Recommendations involving clinical medicine in a CME activity must be based on scientific evidence that is
accepted by the medical community.
Recommendations must conform to the generally accepted standards of experimental design, data
collection and analysis.
The University of Louisville CME&PD (which is an Accredited Provider) has oversight responsibility for the
application and management of all commercial funds involved with accredited CME events.
Please note and follow the University Policy requirements presented at the bottom of the last page.
Complete this document on your computer. You may place your cursor anywhere in the “Click here to enter text” field,
click once and begin typing or cut/paste information. The space will expand to accommodate any data you wish to
present. The ☐ boxes will allow you to place an “X” in the box by placing your cursor over the box and clicking; to
remove an “X” place your cursor over it and click again.
COURSE INFORMATION
1) School/organization/department making request:
Click here to enter text.
2) ☐Provided CME Event (U of L department)
☐Joint-provided CME Event (organization outside of U of L)
1
Revised 03/03/16
If Joint provider, please provide the full name of your organization, current address, phone
number and email address as well as a URL if your organization has a website: Click here to enter
text.
3) Please indicate the learning format for this CME activity:
☐ Live Event/Activity
☐ Internet Live Activity (Webinar)
Hardware requirements: Click here to enter text.
Copyright permission needed?
☐YES (provide documentation)
☐NO
☐None needed
☐ Enduring Material (non-live activity, which endures over time, e.g., videotape, journal
supplement, monograph, CD Rom, podcast, online course).
The mode of delivery (such as the internet, or a print journal) allows the participant to
access the content at any time in any place, rather than only at one time, and one place.
4) Title of course:
Click here to enter text.
5) Course date(s):
Click here to enter text.
6) Course location (include street address, city, state):
Click here to enter text.
7) Please provide a one or two paragraph description of your course. This statement will be used for
promotional materials (brochures, web pages, etc.), as a needs assessment and when applying for
grants. This description should give an overview of the course and inform potential attendees and
supporters as to why this course is important, one that they should be interested in. Click here to enter
text.
8) Number of Physician - CME Credits Requested: Click here to enter text.
Number of Nursing - CEU Credits Requested: Click here to enter text.
(Note: for RN credit you must also submit with this application a current curriculum vitae or biographical sketch
for each listed speaker in the course)
Other professional credits you plan to arrange for this course:
Click here to enter text.
COURSE CONTACTS
9) Name of Course Director: (U of L faculty/administrator or joint-provider administrator):
Click here to
enter text.
E-mail
Click here to enter text.
Telephone
Click here to enter text.
10) Name of Course Coordinator*(a primary contact person closely familiar with the course):
enter text.
E-mail:
Click here to enter text.
2
Click here to
Revised 03/03/16
Telephone:
Click here to enter text.
*Note that the course coordinator will be expected to function in proxy for the CME & PD office in
all matters pertaining to this course. A separate Proxy agreement form will be provided for
review of responsibilities and signature once the course has been approved for credit.
11) Planning Committee Members – Please list all individuals who are on the planning committee
including staff and external members. All CME courses must have a planning committee with a
minimum of three (3) persons and each must complete a Disclosure of Conflict of Interests form.
Please Note: The use of owners and/or employees of ACCME-defined commercial interests as
planners and/or faculty is strictly prohibited in CME activities. Disclosure of COI forms must be
completed, signed and submitted with this application by all Planning Committee members,
Course Director and Course Coordinator, and reviewed/approved by CME & PD prior to the first
Planning Committee meeting.*
NAME & CREDENTIALS
(MD, PHD, ETC.)
TITLE(S) & INSTITUTIONAL
AFFILIATION, LOCATION
*Date of First Planning Committee Meeting: _____________
E-MAIL ADDRESS
______
CONTENT DEVELOPMENT
12) Screening Criteria: In order to be considered for a continuing medical education activity, all of the
criteria listed below must be met. Planners confirm, by agreement, to the following statements:
The content of this activity will be based on evidence that constitutes “best practices.” ☐ Agree
Planners have identified a defined gap that exists between current and best practice. ☐ Agree
This activity will provide educational content aimed at closing the defined gap to result in improved
knowledge, competence, and/or performance, which could result in improved patient outcomes.
☐ Agree
3
Revised 03/03/16
All of the recommendations involving clinical medicine in this CME activity are based on evidence that is
accepted within the profession of medicine as adequate justification for their indications and
contraindications in the care of patients.
☐ Agree
All scientific research referred to, reported on, or used in this CME activity will support or justify patient
care recommendations that conform to the generally accepted standards of experimental design, data
collection, and analysis. ☐ Agree
13) This CME activity is planned to meet the needs of what groups of practicing healthcare professionals
(in other words, your target audience)? List all groups: Click here to enter text.
14) How does the content of this activity match the learners’ current or potential scope of professional
activities?
Click here to enter text.
15) Please cite at least three examples from peer-reviewed literature (scientific/medical journals, etc.)
that support the Professional Practice Gaps for this activity and include the URL Address that leads
directly to the article. Be sure the article is not from an online subscription service that can only be
accessed by your office. These articles should support the identification of the medical practice gaps.
Click here to enter text.
16) Check below which procedures were used to identify the physician practice gaps, i.e. educational
need, between current practice vs. best or evidence-based practice? Please check all that apply.
Attach all appropriate documentation for each item selected.
☐
☐
☐
☐
☐
Requirements by state licensing board, specialty societies
Previous course evaluations
Previous outcomes data
Literature Search
Other, please list: Click here to enter text.
17) Based on the information above please complete the following chart; see notes below for
explanations.
1. What are the learners’ educational needs (practice gaps, what are they currently not doing in their practice
2.
3.
4.
that needs to change)?
What procedures were used to identify the gap (e.g., literature search)? How did you decide that the learner
needs to change how they are practicing and why are they not performing best-practices?
What are the desired results or best practice changes expected; what change should occur in the learners’
practice after they participant in this activity?
What is/are the cause(s) of the gap (do they lack knowledge, do they need to be more competent and/or
does performance need to change)?
1. EDUCATIONAL GAP
current practice
(What they are not doing)
2. PROCEDURES USED
TO IDENTIFY THE
GAP(S) & why they are
not doing it (include a
percentage when
applicable)
3. DESIRED
RESULTS
(best-practice)
4. CAUSE OF GAP
(educational need)
EXAMPLE
Physicians are not using the
current diagnostic criteria to
EXAMPLE
A current literature
search indicates that at
EXAMPLE
Physicians will utilize
best practice
EXAMPLE
Click the boxes that
apply to your program
4
Revised 03/03/16
screen pre-school age
children for Autism.
least 25% of physicians
have not been educated
on the diagnostic
criteria for autism
screening.
Using this template and following
these examples, now state each of
your gaps below.
guidelines in regard
to Autism screening
procedures.
based on the criteria
below
☒Knowledge
Clinicians aren’t
performing as they
should because they
lack knowledge.
☐Competence
Clinicians may “know”
but do not “know
how.”
☐Performance
What clinicians
actually do in
practice...clinical
performance may be
influenced by
knowledge,
competence, or by
factors external to the
individual.
☐Patient Outcomes
Improve patient
outcomes by
diagnosing and
treating the problem.
☐
☐
☐
☐
Knowledge
Competence
Performance
Patient Outcomes
☐
☐
☐
☐
Knowledge
Competence
Performance
Patient Outcomes
18) Based on the desired results described above, list the learning objectives for the content of this
activity. The learning objectives are the bridge to address the GAP between current practice and
best practice. Also, the objectives specify the result that the learner can expect to achieve by
participating in this educational activity. Using the standard behavioral objective stem “As a result of
participating in this activity, participants should be able to . . .” provide the learning objectives for each
major educational portion of the course and number each one. Note: the learning objectives have to be
stated in measurable terms. Start each objective with an active verb (e.g., describe, list, compare, identify,
name, etc.). Avoid vague behavioral terms such as “understand.”
Click here to enter text.
19) Founded on the Maintenance of Certification (MOC) competencies designed by the American Board of
Medical Specialties (ABMS), the competencies established by the Accreditation Council for Graduate
Medical Education (ACGME), the general competencies established by the Interprofessional Education
Collaborative (IPEC), and the desirable physician attributes established by the Institutes of Medicine
5
Revised 03/03/16
(IOM), in the chart below indicate what competency areas you will address in this CME activity and
which learning objectives will fulfill those competency needs?
Check the
boxes
below
that apply
Competencies/Physicians Attributes
Patient Care (provide care that is compassionate, appropriate and
☐
effective treatment for health problems and to promote health).
Medical Knowledge (demonstrate knowledge about established and
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
evolving biomedical, clinical and cognate sciences and their application in
patient care).
Practice-based Learning and Improvement (investigate and
evaluate patient care practices, appraise and assimilate scientific evidence
and improve practice of medicine).
Systems-based Practice (demonstrate awareness of and responsibility
for larger context and systems of healthcare; call on system resources to
provide optimal care, e.g., coordinating care across sites or serving as the
primary case manager when care involves multiple specialties, professions,
or sites).
Professionalism (demonstrate a commitment to carrying out
professional responsibilities, adherence to ethical principles and sensitivity
to diverse patient populations).
Interpersonal and Communication Skills (demonstrate skills that
result in effective communication and teaming with patients, their families
and professional associates, such as fostering a therapeutic relationship
that is ethically sound; using effective listening skills with non-verbal and
verbal communications; working as both a team member and at times as a
leader).
Provide patient-centered care (identify, respect, and care about
patients’ differences, values, preferences and expressed needs; relieve pain
and suffering; coordinate continuous care; listen to, clearly inform,
communicate with, and educate patients; share decision making and
management; and continuously advocate disease prevention, wellness, and
promotion of healthy lifestyles, including a focus on population health).
Work in Interdisciplinary Teams (cooperate, collaborate,
communicate, and integrate care in teams to ensure that care is continuous
and reliable).
Employ Evidence-based Practice (integrate best research with
clinical expertise and patient values for optimum care; participant in
learning and research activities to the extent feasible).
Apply Quality Improvement (identify errors and hazards in care;
understand and implement basic safety design principles; continually
understand and measure quality of care in terms of structure, process and
outcomes in relation to patient and community needs; design and test
interventions to change processes and systems of care with the objective of
improving quality).
Utilize Informatics (communicate, manage knowledge, mitigate error,
and support decision making using information technology).
6
Content in this
activity that
reflects the
competencies you
selected – Cite the
learning objective
number(s) that
apply
Revised 03/03/16
Utilize Effective Teaching Methods (communicate, demonstrate,
☐
☐
☐
☐
☐
coordinate and outline the skills and competencies related to effective
teaching practices in the field of medical education, including
teaching/learning strategies, methods and educational objectives)
Values/Ethics for Interprofessional Practice (Work with
individuals of other professions to maintain a climate of mutual respect and
shared values).
Roles/Responsibilities (Use the knowledge of one’s own role and those
of other professions to appropriately assess and address the healthcare
needs of the patients and populations served).
Interprofessional Communication (Communicate with patients,
families, communities, and other health professionals in a responsive and
responsible manner that supports a team approach to the maintenance of
health and the treatment of disease).
Teams and Teamwork (Apply relationship-building values and the
principles of team dynamics to perform effectively in different team roles
to plan and deliver patient-/population-centered care that is safe, timely,
efficient, effective, and equitable).
20) Please provide a TIMED AGENDA, the contents of which will address the educational needs of the
target audience (you can cut and paste into the “click here to enter text” space below):
Click here to enter text.
21) List only your confirmed speakers/presenters and moderators in the table below. You must include
their Professorial Rank, and/or Business Title, Institutional Affiliation and a Current Email Address. It is
assumed that your planning committee has selected the most qualified professionals to present this
material. We strongly recommend that you arrange for a signed disclosure form from each
speaker/presenter at the time you contract with them to speak at this event.
Please Note: The use of owners and/or employees of ACCME-defined commercial interests as
planners and/or faculty is strictly prohibited in CME activities. Please note that final credit
approval cannot be determined until all speaker’s/presenters and moderators disclosure forms
are provided to CME & PD. Send those forms with your application submission, or as soon as
possible.
NAME & CREDENTIALS
(MD, PHD, ETC.)
TITLE(S) & INSTITUTIONAL
AFFILIATION, LOCATION
7
E-MAIL ADDRESS
Revised 03/03/16
EDUCATIONAL DESIGN
22) What are the learning/educational format(s) for this CME activity? (check all that apply)
☐
☐
☐
☐
☐
☐
☐
Didactic Lecture
Skilled demonstration
Case Studies
Audience Response System
Simulations
Self-directed Study
DVD or ☐ CD/ROM ☐ Online Video
☐
☐
☐
☐
☐
☐
☐
Question and Answer session
Panel Discussion
Lab activity
Internet
Teleconference
Print
Other (describe): Click here to enter text.
23) Briefly explain how the learning/educational format(s) is appropriate for the setting, objectives and
the results for this educational activity: Click here to enter text.
24) CME&PD will deliver a post-course online evaluation to evaluate and analyze changes in your
learners’ professional practice gaps (i.e., change in knowledge, competence, performance). Three months
after the completion of the activity, CME&PD will send a follow-up outcomes survey to measure sustained
changes in knowledge, competence, performance and/or patient outcomes achieved in this activity. The
outcomes survey is sent to all participants who submitted the initial evaluation and received CME credit.
However, you are encouraged to explore other ways to determine learner competency and understanding
of the course content. Please describe any additional plans such as post-course content evaluations or
your own follow-up survey, etc. Click here to enter text.
25) Planners should address anticipated barriers that physicians may have in trying to implement the
ideas and methods delivered in this course. Barriers may include: formulary restrictions, insufficient time
for implementation of new skills or behaviors, lack of insurance reimbursement, lack of organizational
support, lack of resources, policy issues within the organization. Identify those barriers in the chart
below that might impact participants of this activity to change and then recommend educational
strategies that you will present in this activity designed to alleviate these barriers.
ANTICIPATED BARRIER(S) TO PHYSICIAN CHANGE
PLANS TO ADDRESS THE BARRIER(S)
26) Planners of this activity are encouraged to employ non-educational strategies to reinforce the
intended results of this activity (see examples below). Please list additional non-educational strategies
that you will use:
8
Revised 03/03/16
NON-EDUCATIONAL STRATEGY
Example-CME&PD will encourage all participants of
this activity to implement some of the new information
and/or techniques into their practice.
Purpose of the Strategy
Example-Encourage participants to change as a
result of attending this activity.
Example-Email an outcomes survey to participants
who completed the evaluation.
Example-The outcomes evaluation will allow
participants to share changes implemented into
practice and changes in patient outcomes as a
result of attending this activity.
27) Please identify factors outside your or the physician’s control that may impact patient outcomes:
Click here to enter text.
COURSE LOGISTICS
28) Will this activity be supported by grants? ☐Yes ☐No
If yes, then please list each grant source in the chart below; CME&PD must receive all Letters of
Agreement in advance of the program to be submitted for University review and signatures
along with copies of the grant checks as they become available.
SOURCE OF GRANT
CONTACT PERSON
E-MAIL ADDRESS
29) Please list the names of all speakers, moderators, panel members, and their honorarium amounts,
travel expenses length of presentation. If no honorarium or travel is to be paid, please indicate with “NA.”
COURSE DIRECTOR, CO-DIRECTOR,
SPEAKERS, MODERATORS, PANEL
MEMBERS (ANYONE PRESENTING)
HONORARIUM
9
TRAVEL AND
ACCOMMODATION
EXPENSES
TOTAL
AMOUNT OF
TIME
SPEAKING
Revised 03/03/16
CME&PD PROGRAM INFORMATION
30) Is there a registration fee for participants in this event? ☐Yes
☐No
If yes, how much for each category?
U of L Physicians
$ Click here to enter text.
All other non-physician U of L Faculty $ Click here to enter text.
U of L Nurses
$ Click here to enter text.
Outside Physicians
Outside Nurses
$ Click here to enter text.
$ Click here to enter text.
U of L students/residents/fellows
$ Click here to enter text.
(U of L Trainees are not to be charged fees other than for catering and workshop supplies at University cost)
Others (please specify):
$Click here to enter text.
31) Is any part of this live event to be available online, to be video recorded or are there other special
technical support requirements? If yes, there will be an additional charge – CME&PD will contact you to
discuss this additional charge.
☐Yes (please specify details): Click here to enter text.
☐No
If you answered “Yes” you will be contacted by CME&PD for follow-up details and charges.
CME&PD ACTIVITIES ADMINISTRATIVE FEE POLICIES
Please note that Continuing Medical Education & Professional Development (CME&PD) is required by the University of Louisville
School of Medicine to be a self- supporting, non-profit office. Fees are used to pay for accreditation expenses, staff salaries, and office
overhead. Much of our work involves assuring that the proposed course meets all ACCME accreditation criteria and standards as
well as maintenance of CME credit data, reporting physician CME credit activity to the Greater Louisville Medical Society and
providing additional professional services that are intended to prepare and position your program for greater success.
Schedule of Fees For Accredited CME and Related Programming
Basic fee charges cover the following essential services: 1) vetting, review and approval of your CME application, 2)
review and approval of promotional materials, 3) ACCME accreditation fees, 4) online evaluation development and
summary, 5) online certificates processing, 6) data base management of individual CME credits, 7) transcript
10
Revised 03/03/16
services, 8) uploading Category 1 credits to Greater Louisville Medical Society, and 9) outcomes survey
management (60-90 days after live event).
PROVIDED (U of L Departments) CME Activity
Additional fee for Nursing credit also in CME Activity
Fee $2,000*
Fee $300
Nursing ONLY Activity (No CME)
JOINT-PROVIDED (non-UofL organizations) CME activity
Fee $2,000*
Fee TBD*
*Plus Credit-hour Fee (for total number of Category 1 hours)
Total hours X $100
Example: A full-day continuing education course, offering CME credit and nursing credit for a total of 7
Category 1 hours would be : $2,000 (CME fee) + $300 (Nursing credit fee) + 7 x $100, for a grand total of
$3,000 for the accreditation expense. Nursing credit is provided by the Kentucky Board of Nursing through the
University of Louisville Hospital; CME&PD will coordinate with ULH for your nursing credit.
Note: In situations where speaker conflict of interest issues arise it will be necessary to review the course material
that speaker will be using in his/her presentation. CME & PD will arrange for a peer reviewer from among the UofL
faculty and an honorarium will be paid to the reviewer at the rate of $100/hour of review time or $75/slide deck
review. These charges to be paid out of program/course funds.
Note: If this is an Enduring Materials Course: After initial course/credit fees charged for the first year, an additional
fee of $500 for each additional year of accreditation (up to a maximum of three years) will be charged.
CME&PD will confirm total charges based on the above fee schedule and costs for additional services (see next page)
upon presentation of the application for review and approval by the CME&PD Advisory Board. Select your
additional services in the chart below.
Program Accreditation Fees
PROVIDED (U of L Departments) CME Activity
Fee $2,000
$___________________
JOINT- PROVIDED (non-UofL organizations) CME activity
Fee TBD
$___________________
Additional fee for Nursing credit also in CME Activity
Fee $300
$___________________
Nursing ONLY Activity (No CME)
Fee $2,000
$___________________
*Plus Credit-hour Fee (for total number of Category 1 hours)
Total hours X $100
$___________________
Total Accreditation Fee
$___________________
Additional CME/PD Services and Fees
These services are designed to provide skilled assistance with the various elements of your program, from webpage
design and online registration to post-course services. Please check the left-hand box for the additional services you
need and note the total charge for each item. Charges do not include vendor costs such as printing, address lists,
postage, site rental, catering, AV, etc.
CHECK THE
SERVICES
YOU WANT
ITEM
EXPLANATION OF SERVICES & COSTS
11
TOTAL $$$
Revised 03/03/16
CME/PD TO
PROVIDE
☐
Web page and announcements
Set up webpage on CME & PD website
$350
☐
Course Marketing
Send out e-mail announcements to HSC
Faculty, CME/PD Past Participants and
posting in UofL Today online
$150
☐
Online Registration Set Up &
Processing
Credit cards charged, online receipts
provided, and confirmations emailed
$250
☐
Online Registration Fee
3% of tuition per registrant (this is a
credit card charge, not a CME & PD
charge)
TBD
☐
Program Financial
Management Fee
Deposit grant and exhibit checks,
process CC exhibit fees, coordinate
venue contracts and approvals. Process
invoices, general bookkeeping, prepare
final budget, etc.
$300
☐
Honorarium &
Reimbursement Payments
CME/PD collects receipts & W-9
information from faculty and pays
reimbursements & honoraria.
$300
☐
Online Course Build
Build of Online Enduring Material on
the CME Tracker platform (up to 4 1hour modules)
$250
☐
Presentation Download
Course slide sets downloaded to a CME
& PD course webpage
$300
☐
Course Material Download
Course Brochure, Syllabus, and
additional course information
downloaded or linked to a CME & PD
course webpage
$300
CME & PD
Homepage Announcement
Course published to the CME & PD
homepage upcoming events
No charge
CME & PD
Certificates & Online
Transcript Assess
Online access. Included in accreditation
fee
No charge
12
Revised 03/03/16
CME & PD
Online Evaluation
Included in accreditation fee – Develop
& Set-up online course evaluation and
follow-up outcomes evaluation three
months after activity.
No charge
Brochure and Poster Development
University of Louisville Design and Printing Services will work with you to develop your course brochures, flyers,
and posters at a standard design charge of $80/hr. For a brand new upstart the charge will be 3-5 hours ($240$400) for a standard tri-fold brochure or flier. Design and Printing Services has an istockphoto.com account and can
purchase photos from there. Currently, the price is $2/credit and photos for promotional materials will likely run
from 12-25 credits per photo.
To begin design of your promotional materials please contact:
Heather L. Jones
Graphic Designer
Design and Printing Services
University of Louisville
P: 852-0716
E: heather.jones.1@louisville.edu
33) Budget Planning: Course fees, Anticipated Income and other Expenditures
This section must be completed in compliance with ACCME Essentials and Standards; the
management of your course funding is critically important to the ascertaining of independence in the planning and
presentation of CME activities that are free of commercial influence. Please prepare a draft of your budget after
reviewing the charges for administrative fees and additional CME & PD services – as described in the previous two
sections. You may contact the CME & PD office for further information as you complete this part of the application.
THE FOLLOWING TEMPLATE WAS DESIGNED TO HELP YOU DRAFT YOUR BUDGET
(ALL CME COURSE APPLICATIONS MUST INCLUDE A BUDGET PLAN)
Program Title: Click here to enter text.
Program Date: Click here to enter text.
1.
Please add anticipated costs for services in the Expenses Column.
2. You may provide your own budget layout using an Excel spread sheet or similar format.
CHECK
PROGRAM ELEMENTS
ANTICIPATED EXPENSES
☐
☐
☐
☐
☐
EXPENSES
AMOUNT
ACCME Category 1 Credit + number of hours – from CME/PD Fee schedule
Advertising - journals, newspaper, TV, professional websites
Audio Visual Services
Brochure Development (UofL Design and Printing Services cost - $80/hour)
Brochure Printing Cost (UofL cost - Usually $.50 to $1 per brochure)
13
Revised 03/03/16
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Brochure Postage & handling Cost (UofL cost - $.34 bulk rate, $.45 1st class)
Brochure – estimated cost of mailing labels for brochure
Catering and Site arrangements
Disclosure and Conflict of Interest Resolution – CME/PD ($100 per hour of
presentation review or $75/slide deck review)
Faculty Honoraria (includes course director and developer stipends)
Faculty Housing Expense
Faculty Travel Expense
Name badges – Usually cost $2 per badge
Online Registration Setup– CME & PD ($250)
Online registration Charge (via authorize.net – 3% charge per participant)
Online course development
On-site registration
Poster Development UofL Design and Printing Services ($80/hour does not
include cost of printing)
Syllabus and course material downloaded onto the CME/PD website
Syllabus/handouts copying - Usually $10 to $15 per syllabus
Webpage Development & send e-mail announcement pdf to CME/PD past
participants (you provide an Excel file list) and School of Medicine Faculty ($350)
Miscellaneous and Incidental Expenses
TOTAL OF ESTIMATED EXPENSES OF THIS ACTIVITY
ANTICIPATED INCOME
☐
☐
☐
☐
AMOUNT
Educational Grants
Exhibitor Fees
Registrant Fees
Other Income (provide details of source(s)
TOTAL ANTICIPATED INCOME FOR THIS ACTIVITY
A Final Comment:
While it is understood that the costs and income presented in this program budget are estimates, it is the
responsibility of the providing department or joint provider to monitor and manage all budgetary matters
and to assume responsibility for program losses. Continuing Medical Education & Professional
Development does not share in the profit or loss of any program which we accredit. In addition to
accreditation services we will, at program’s expense, provide additional registration and program
element support (as described above). Program counsel and guidance is always gratis. Our primary
concern is for the academic and educational integrity of the program course materials and for the
determination of appropriate CME Category 1 credit based upon ACCME Criteria and Commercial Support
standards. We look forward to working with you in providing this valuable service to our health care
professionals and will do all we can to assist you in realizing a highly successful program.
The Staff of Continuing Medical Education & Professional Development
Email:
cmepd@louisville.edu
14
Revised 03/03/16
Phone:
Website:
Mail:
(502) 852-5329
http://louisville.edu/medicine/cme
Continuing Medical Education & Professional Development
Med Center One
501 East Broadway, Suite 370
Louisville, KY 40202
Please note:It is your responsibility to apply for continuing education credit other than ACCME (physician) and
Kentucky Board of Nursing (registered nurses) and you may do so by clicking on the following links:
AAFP Credit - http://www.aafp.org/online/en/home/cme/cmea.html?navid=cme+accreditation
Social Work Credit - http://bsw.ky.gov/forms/Pages/other.aspx
Nurse Practitioner Credit – http://www.aanp.org/education/ce-accreditation/individual-program-accreditation
Pharmacy Credit - http://www.acpe-accredit.org/ceproviders/application.asp
Psychology Credit http://psy.ky.gov/Forms%20Library/Continuing%20Education%20Program%20Application.pdf
This completes your CME credit application. Please review the following notes and procedures as
you prepare to submit your materials. If you have any questions call a CME&PD staff member.
Course Director please sign electronically on the next page.
Notes:
This complete application must be accompanied by :
 a budget plan for the event
 any request for any additional services (for which there may be additional fees)
 a listing of procedures which were used to determine the Educational Gap(s) from question #17
Prior to marketing your program/event you should submit to CME&PD:
 a draft brochure (and/or draft of your website promotion) for our review and approval before mailing or
website launch (if not being developed by CME&PD)
 three (3) copies of your original brochure (if not developed by CME&PD)
At least 30 working days prior to the date of the CME event you should submit to CME&PD:
 all letters of agreement (LOA) with grant sponsors; these must be between 1) the University of Louisville
Research Foundation, 2) the commercial/grant sponsor, and 3) the joint provider, and must be signed by
legal representatives of all three entities (CME&PD will arrange for UofL signature).
 disclosure forms from everyone involved in the activity (including planners, course director, coordinator,
speakers, panelists, etc.)
 proxy form (all events)
Following completion of the CME event, the following items must be submitted in a course wrap-up report to
CME&PD for review and permanent filing:
 Faculty/course director reimbursement amounts for travel and lodging etc. (if not paid by CME&PD)
reported on the final budget
 Faculty/course director honoraria amounts (if not paid by CME&PD) reported on the final budget
Note: commercial supporters are not permitted to directly pay faculty/course director honoraria or any
course expenses
 Copies of Grant checks (if money is not collected by CME&PD)
 Final Budget reconciliation - accounting of income and expenses (if not handled by CME&PD).
Your application and/or proper closure for this event is considered incomplete without each of these pieces
of documentation, and withdrawal of credit may occur without full cooperation.
Signature/Date (electronic) of Course Director:
Click here to enter text.
15
Revised 03/03/16
IF THIS ACTIVITY IS CANCELED WITHIN 30 DAYS OF THE START DATE, THERE WILL BE A $500
CANCELLATION FEE PLUS COLLECTION OF ANY EXPENSES INCURRED BY CME&PD.
Continuing Medical Education & Professional Development does not share in profit or loss for this CME Event.
Continuing Health Medical Education & Professional Development (CME&PD) CME Events are reviewed by the
Continuing Medical Education & Professional Development Advisory Board for scientific content, relevance to
healthcare professionals, congruence with the CME&PD mission, appropriate management of commercial interest
involvement, and credentials of speakers. All CME Events must be approved by the CME&PD Advisory Board. By serving
in this role, the members of the Board are serving as part of the planning process for all CME Events provided by the
University of Louisville CME&PD. Conflict of interest disclosures of CME&PD Advisory Board members and CME&PD
Staff must be included on the event welcome letter and CME&PD will provide the most current rendering of that
information to the course developers.
NOTE: For all accredited CME programming The University of Louisville Continuing Medical Education & Professional
Development office operates in strict adherence to the University Policies and Procedures regarding issues of nondiscrimination and equal opportunity, Americans with Disabilities Act, and institutional policies regarding nepotism and
conflict of interest. All program developers are advised to review these policies at the following websites:
https:/sharepoint.louisville.edu/sites/policies/library/SitePages/Administration/Addressing%20Potential%20Individual%
20Conflict%20of%20Interest%20Policy%20and%20Procedures.aspx and https://sharepoint.louisville.edu/sites/policies/
library/SitePages/Human%20Resources/Nepotism.aspx. Full disclosure of program funding sources, payment of honoraria
and contracted services is expected before, during and following the accredited event.
16